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 The Easy
Guide to

Focused History Taking for

OSCEs
Second Edition
 The Easy
Guide to

Focused History Taking for

OSCEs
Second Edition

David McCollum MB ChB

GP Registrar, Leeds

Boca Raton London New York

CRC Press is an imprint of the

Taylor & Francis Group, an informa business
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
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© 2017 by Taylor & Francis Group, LLC

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Library of Congress Cataloging‑in‑Publication Data

Names: McCollum, David (Doctor), author.

Title: The easy guide to focused history taking for OSCEs / David McCollum.
Other titles: Focused history taking for OSCEs | Easy guide to focused
history taking for objective structured clinical examinations
Description: Second edition. | Boca Raton : CRC Press, [2017] | Preceded by
Focused history taking for OSCEs : a comprehensive guide for medical
students / David McCollum [and others]. c2013. | Includes index.
Identifiers: LCCN 2016054173| ISBN 9781138196520 (paperback : alk. paper) |
ISBN 9781138743281 (hardback : alk. paper) | ISBN 9781315181783 (master eBook)
Subjects: | MESH: Medical History Taking--methods | Physical Examination |
Examination Questions
Classification: LCC R834.5 | NLM WB 18.2 | DDC 610.76--dc23
LC record available at https://lccn.loc.gov/2016054173

Visit the Taylor & Francis Web site at

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http://www.crcpress.com
 Contents

Foreword to the first edition ix

Foreword to the second edition xi
Preface xiii
Acknowledgements xv
Author xvii
Abbreviations xix
Taking a focused history in OSCEs – The Calgary–Cambridge model xxi
General OSCE tips xxix
Tips for approaching a history-taking OSCE station xxxiii
Example history – Knee pain xxxv
OSCE marking scheme – Manchester Medical School xli

1 General medicine and geriatrics

Tired all the time 1
Falls 6
Pyrexia (adults) 9
Rash 13
Bruising 17
2 Cardiorespiratory medicine
Chest pain 21
Dyspnoea 26
Palpitations 30
Cough 34
Haemoptysis 38
3 Gastroenterology
Dysphagia 43
Haematemesis 47
Change in bowel habit (constipation/diarrhoea in adults) 51
Jaundice 55
4 Neurology
Collapse and seizures 61
Headache 65
Weakness 70
Altered sensation 74

v
 Contents

5 Musculoskeletal medicine
Back pain 79
Joint pain 83
6 Surgery
Abdominal pain 87
Bleeding per rectum 92
Lumps, bumps and swellings 96
Weight loss 99
Intermittent claudication 103
7 Urology/renal medicine
Haematuria 107
Dysuria 112
Polyuria 116
8 Ear, nose and throat
Dizziness and vertigo 121
Neck lumps 125
Earache 129
Hearing impairment (adult) 133
Sore throat 137
9 Ophthalmology
Painful red eye 141
Loss of vision/blurry vision 145
10 Obstetrics and gynaecology
Gynaecological history template 151
Vaginal bleeding 153
Antepartum haemorrhage 157
Vaginal discharge 161
Subfertility 164
Urinary incontinence 168
Amenorrhoea/oligomenorrhoea 172
11 Paediatrics
Paediatric history template 177
Vomiting 179
Failure to thrive 183
Convulsions 186
Developmental delay 190
Pyrexia (paediatric) 195
Behaviour 199

vi
 Contents

12 Psychiatry
Low mood/depression 203
Anxiety 207
Hallucinations/delusions 211
Forgetfulness 215
Mania 219
Alcohol history 223
Eating disorder 228
Self-harm/suicide attempt (risk assessment) 232
Index 237

vii
 Foreword to the first edition

The OSCE examination or its equivalent is rapidly becoming the gold standard in how the clini-
cal knowledge, acumen and skills of undergraduate medical students and postgraduate medical
trainees are tested in a controlled and reproducible clinicomimetic environment.
In Manchester at any one time we have in excess of 2200 medical students. Our programme
is specifically designed to train students to be independent learners and to set them up for life
as doctors in the rapidly changing world of modern medicine and healthcare.
For a student, this book is a perfect learning resource for approaching a whole series of clini-
cal problems. But it goes further, eloquently showing how to construct a successful approach
to any clinical problem. I thoroughly recommend this book to all clinical students. If you read
it you will learn a great deal about specific medical problems, see how to approach common
clinical scenarios and, perhaps more importantly, learn how to analyse a clinical setting and
efficiently extract the information necessary for diagnosis and the initiation of management.
This really is a super little book that goes further than just showing how to pass an exam, but
rather equips the reader with a philosophical approach to any clinical problem. Congratulations
to all the authors, but especially David McCollum, who as a fifth-year medical student at
Manchester was the life force behind this book.

Professor Anthony Freemont

Head of Undergraduate Medical Education
and
Professor of Osteoarticular Pathology
University of Manchester

ix
 Foreword to the second edition

As a GP trainer and training programme director on the Leeds GP training scheme, I spend a lot
of time teaching consultation skills. It was a real pleasure to read this book and see the empha-
sis on consultation and communication skills, starting with the excellent Calgary–Cambridge
model. Fully exploring the patients’ perspective of their illness (including their ideas, concerns
and expectations) is not only polite and courteous but also an easy and powerful way of collect-
ing important and relevant information about the case.
All of the cases in this book can present in a 10-minute GP appointment, and it is our com-
munication skills every bit as much as our other medical skills that enable us to formulate a
management plan. General practice is a highly rewarding career where these communication
skills are fundamental to daily practice.
I heartily recommend this book, particularly the introductory chapter, which highlights how
you can construct a medical interview in a time-efficient and effective manner. Good luck with
your exams.

Dr Simon O’Hara
General Practitioner
Training Programme Director
Leeds VTS

xi
 Preface

A good general practitioner will tell you that most diagnoses are made from clinical history
alone and not from examinations or investigations. Following on from the success of the first
edition, Focused History Taking for OSCEs, comes the second edition, The Easy Guide to Focused
History Taking for OSCEs.
The second edition incorporates feedback received from the first edition and ensures the
text is up-to-date at the time of publishing. The introductory chapter tackles how to construct
histories using the Calgary–Cambridge framework and how to approach history-based OSCE
stations. This includes tips from recently qualified doctors and a highly respected examiner.
New features for this edition include blue boxes within each history to highlight the red flag
symptoms, references to current NICE clinical knowledge summaries and guidelines, as well
as more illustrations. Whilst maintaining a simple layout, the histories have been re-structured
to mirror the Calgary–Cambridge model of consultations that is widely taught throughout the
United Kingdom and abroad. New and updated histories have been written for this edition
with each history also considering differential diagnoses, investigations and management.
This book is a comprehensive guide to history taking to suit modern medical student exami-
nation purposes. This book provides a database of histories based on common scenarios in
student examinations across the United Kingdom.

David McCollum
GP Registrar
Leeds

xiii
 Acknowledgements

Colleagues from many specialities throughout medicine and surgery have contributed to
the production of this book. Each chapter has been written by well-respected doctors and
reviewed by experts in their respective field. I would like to thank those, including several
family members, who have helped either in writing or reviewing chapters in this book as well
as the previous edition.

AUTHORS FROM THE FIRST EDITION

Professor Peter McCollum, MB BCh MA MCh FRCSI FRCSEd, Professor of Vascular
Surgery/Hon Consultant Vascular Surgeon, Hull York Medical School/Hull & East Yorkshire
Hospitals NHS Trust. As co-author of the first edition, Peter helped to write the introduc-
tory and surgical chapters in the first edition of the book as well as reviewing the other
chapters in the book. Peter has extensive experience in examining at all levels of medical
and surgical training including medical student OSCEs across the United Kingdom. He has
been a member of council and deputy exam convenor in the Royal College of Surgeons of
Edinburgh.

Dr Graham McCollum, MB BS BSc, Ophthalmology registrar and co-author of the first edi-
tion. Graham helped to write the general medicine, cardiorespiratory, urology and ophthal-
mology chapters in the first edition. Graham graduated from Hull/York Medical School in
July 2012.

Dr Priha McCollum, MB ChB, GP registrar and co-author of the first edition. Priha helped
to write the gastroenterology and obstetrics and gynaecology chapters, as well as review-
ing the other chapters in the book. Priha graduated from the University of Manchester in
July 2011.

CONTRIBUTORS TO THE FIRST EDITION

Dr Thomas Hansen (Acute Care Common Stem trainee) and Mr Kevin Morris (Consultant
Neurosurgeon) for helping to write and review the neurology chapter, respectively;
Dr Suparna Dasgupta (Consultant Paediatrician) for helping to review the paediatric
c­hapter; Dr Amit Sindhi (Specialist Registrar, Psychiatry) for helping to write and review
the ­psychiatry chapter; Mr Sachchidananda Maiti and Mrs Wendy Noble (Consultants,
Obstetrics & Gynaecology) for helping to review the obstetrics and gynaecology chapter;
Dr Rachel Gorodkin (Consultant Rheumatologist) for helping to review the musculoskel-
etal and general medicine chapters; Dr Patrick Newman (General Practitioner) for helping
to review the general medicine chapter; Dr David Ahearn (Consultant, Elderly Medicine) for
reviewing the gastroenterology chapter; Professor Andrew Clark (Professor of Cardiology) and

xv
 Acknowledgements

Dr Simon Hart (Consultant Respiratory Physician) for helping to review the cardiorespiratory
chapter; Mr Sigurd Kraus (Consultant Urologist) for helping to review the urology chapter;
Mr Jim Innes (Consultant Ophthalmologist) for helping to review the ophthalmology chapter.

CONTRIBUTORS TO THE SECOND EDITION

Dr Sharfaraz Salam (Neurology Clinical Fellow) and Mr Justin Murphy (Consultant Head and
Neck Surgeon) for reviewing the neurology and ENT sections, respectively.

xvi
 Author

David McCollum, MB ChB, graduated from the University of Manchester’s Medical School in
July 2012 with MB ChB. He completed his foundation training at University Hospital of South
Manchester and The Christie Hospital in Manchester. His foundation jobs included general
surgery, general medicine, respiratory medicine, emergency medicine, general practice and
oncology at the renowned Christie Hospital. He now lives and works in Leeds and is in the final
year of the Leeds GP Vocational Training Scheme. As part of this training, he has done jobs in
elderly medicine, emergency medicine and ENT, as well as having worked as a GP registrar at
Leeds Student Medical Practice and in his current job at Meanwood Health Practice.
David McCollum’s interests include medical education, rheumatology and ENT, for which he
is looking to pursue additional qualifications. He has previously been involved in co-ordinating
regional teaching events in Manchester in the past, including Fit For Finals, a revision course
designed for final year medical students. He is keen to become more involved in undergraduate
and postgraduate education after gaining his completion of training certificate in general practice.

xvii
 Abbreviations

A&E Accident and Emergency department FH Family history

ABG Arterial blood gas FSH Follicle-stimulating hormone
ACE Angiotensin-converting enzyme G6PD Glucose-6-phosphatase dehydrogenase
ACS Acute coronary syndrome GIT Gastro-intestinal tract
ADHD Attention-deficit hyperactivity disorder GORD Gastro-oesophageal reflux disease
ALP Alkaline phosphatase GUM Genito-urinary medicine
ALS Advanced life support GUT Genito-urinary tract
ALT Alanine transaminase GP General practitioner
ANA Anti-nuclear antibodies GT Glutamyl transferase
ANCA Anti-neutrophil cytoplasmic antibodies GTN Gliceryl trinitrate
BMI Body mass index hCG Human chorionic gonadotropin
BNP Brain natriuretic peptide HDL High-density lipoprotein
BPH Benign prostatic hyperplasia HLA Human leucocyte antigen
BPPV Benign paroxysmal positional vertigo HPC History of presenting complaint
CBT Cognitive behavioural therapy HIV Human immunodeficiency virus
CKS Clinical knowledge summary HPV Human papilloma virus
CMV Cytomegalovirus HRT Hormone replacement therapy
COCP Combined oral contraceptive pill IBD Inflammatory bowel disease
COPD Chronic obstructive pulmonary disorder IBS Irritable bowel syndrome
CRP C-reactive protein ICE Ideas, concerns and expectations
CT Computed tomography ICP Intracranial pressure
CTD Connective tissue disorder IHD Ischaemic heart disease
CTPA Computed tomography pulmonary IM Intramuscular
angiography IMB Intermenstrual bleeding
CVS Cardiovascular system IV Intravenous
DAT Dopamine transporter KUB Kidneys, ureter and bladder
DEXA Dual-energy x-ray absorptiometry LDL Low-density lipoprotein
DH Drug history LFT Liver function test
DMARD Disease modifying anti-rheumatic drug LH Luteinising hormone
DVLA Driver and vehicle licensing agency LMN Lower motor neuron
DVT Deep vein thrombosis LMP Last menstrual period
EBV Epstein-Barr virus LOC Loss of consciousness
ECG Electrocardiography LRTI Lower respiratory tract infection
EEG Electroencephalography MDT Multi-disciplinary team
eGFR Estimated glomerular filtration rate MRI Magnetic resonance imaging
ENT Ear, nose and throat MSK Musculoskeletal system
ESR Erythrocyte sedimentation rate MSU Mid-stream urine sample
FAST Focussed assessment with sonography for NAI Non-accidental injury
trauma NS Neurological system
FBC Full blood count NSAID Non-steroidal anti-inflammatory drug

xix
 Abbreviations

OSCE Objective structured clinical examination SH Social history

OSLER Objective structured long examination record SIADH Syndrome of inappropriate antidiuretic
PC Presenting complaint hormone hypersecretion
PCB Postcoital bleeding SLE Systemic lupus erythematosus
PCI Percutaneous coronary intervention SP Simulated patient
PCR Polymerase chain reaction SSRI Selective serotonin re-uptake inhibitor
PE Pulmonary embolism STI Sexually transmitted infection
PET Positron emission tomography TB Tuberculosis
PMB Postmenopausal bleeding TFT Thyroid function test
PMH Past medical history TNF Tumour necrosis factor
PR Per-rectal U&E Urea and electrolyte
PRN Pro re nata (as required) UMN Upper motor neuron
PSA Prostate-specific antigen URTI Upper respiratory tract infection
PUO Pyrexia of unknown origin USS Ultrasound scan
PUVA Psoralen Ultraviolet A (photochemotherapy) UTI Urinary tract infection
PV Per-vaginal VEGF Vascular endothelial growth factor
RA Rheumatoid arthritis y/o Years old
RS Respiratory system

xx
 Taking a focused history
in OSCEs – The Calgary–
Cambridge model

An OSCE history station is quite similar to the real life situation faced by general practitioners
where they often have only 5–10 minutes to take a history (± examining the patient) and gener-
ate a working diagnosis with a management plan. As such, the Calgary–Cambridge model of
interview is extremely useful in its application.
One of the challenges medical students and doctors alike often face is the perceived battle
between the traditional medical history and the modern communication model of interview.
The communication model however should be viewed as the process of interview and the tradi-
tional medical history viewed as the content you wish to obtain. Using communication models
such as the Calgary–Cambridge model allows you to acquire more information in the history,
including sequencing of events and the patient’s perspective of the illness. The process allows
collection of past medical history, drug history, etc., in the background information aspect of
the model.
The Calgary–Cambridge model is the most commonly used and promoted model in medical
schools throughout the United Kingdom and abroad. The core concepts of the model are sum-
marised in the following sections.

Initiating the session

Gathering information

Providing Building the

structure Physical examination relationship

Explanation and planning

Closing the session

The Calgary–Cambridge model of consultation (Kurtz and Silverman).

xxi
 Taking a focused history in OSCEs – The Calgary–Cambridge model

INITIATING THE SESSION

PREPARATION
• Before starting – ensure appropriate positioning of seats and the absence of physical
barriers between patient and doctor; paper/computer to document if required.

ESTABLISH INITIAL RAPPORT

• Greeting – greet the patient, confirm his/her name and date of birth.
• Introduction – introduce yourself and describe your role; explain the reason for
interview, obtain consent and explain confidentiality if necessary (as a doctor, this is
generally assumed; as a medical student, however, it is polite to explain if the interview is for
your own benefit, discuss confidentiality and seek their consent in this instance).
• Respect – demonstrate interest, concern and respect for the patient as a person; ensure
the patient’s comfort.

IDENTIFY THE REASON(S) FOR CONSULTATION

• Opening question – use an appropriate opening question to identify problems/issues
that the patient wishes to discuss (e.g. “What concerns brought you to the hospital/
clinic?”).
• Listen – listen attentively without interrupting the patient’s opening statement.
• Screening – check and confirm the list of problems or issues that the patient wishes to
cover (“What other problems have you noticed?” or “Is there anything else you would
like to bring to my attention?”).
• Agenda – negotiate an agenda taking both the patient’s and physician’s needs into
account; in most OSCEs this will be self-evident to both parties.

GATHERING INFORMATION

BIOMEDICAL PERSPECTIVE
• Sequence of events – encourage the patients to tell their story from the beginning.
• Question style – use both open-ended and closed questions; move appropriately
from open to closed; at the start of the history use open questions predominantly,
but as the history progresses more closed questions are often required to clarify finer
details.
• Listening – listen attentively; allow the patient to complete statements without
interruption; leave pauses for the patient to think before answering.
• Facilitative response – facilitate the patient’s responses verbally and non-verbally
(use encouragement, silence, repetition, paraphrasing, interpretation).
• Cues – pick up verbal and non-verbal cues (body language, speech, facial expression,
affect); check them out and acknowledge as appropriate (e.g. “you seem tired”); look for
props (medications, cigarette packets, Internet print-out etc.).

xxii
 Taking a focused history in OSCEs – The Calgary–Cambridge model

• Clarification – clarify any statements which are vague (e.g. “Could you explain what you
mean by light headed?”).
• Time framing – clarify dates and sequence of events.
• Summarise – periodically recap to verify your understanding and check chronology
of events; allow the patient an opportunity to correct your interpretation and
provide further information; this is particularly important in exams as it also
allows the examiner to see that you have picked up and acknowledged important
information.
• Language – use concise, clear and easily understood questions; avoid jargon.

The biomedical perspective is the part of the process where the majority of the traditional “history
of presenting complaint” is likely to be ascertained.

THE PATIENT’S PERSPECTIVE

• Effects on life – determine the effects of the problem(s) on the patient’s life. Use
cues previously mentioned by the patient to reflect on potential problems they
might have.
• Feelings and thoughts – encourage the expression of the patient’s feelings and
thoughts; consider if the problem has had a significant effect on the patient’s mood.
• Ideas and concerns – fully explore the patient’s ideas (i.e. beliefs about what is
causing their problems) and concerns regarding each problem (i.e. what are they concerned
could be causing their problem and what in general is worrying them about their problem
(e.g. no one to feed pets if admitted); establish their main concern; in an exam setting, a lot
of key information may be locked behind fully exploring the patient’s ideas and concerns
(listen attentively for cues dropped along the way).
• Expectations – establish what the patient expects from the consultation.

BACKGROUND INFORMATION
• Past medical history
• Drug and allergy history
• Family history
• Personal and social history – much of this section can be picked up in the
“patient’s perspective” part of the history. This part of the history can therefore
be a useful way of double-checking the effect the problem has had on their life.
Consider their relationships, work-life and support mechanisms if relevant.
Clearly this will be more important in certain histories e.g. of chronic disease
than in others.
• Systems review – start with an open question e.g. “Have you noticed any
other symptoms?” Then ask questions relevant to the appropriate system being
explored as well as a quick check on other systems (only if relevant to the presenting
problem).

xxiii
 Taking a focused history in OSCEs – The Calgary–Cambridge model

PROVIDING STRUCTURE
• Summarise – at the end of a specific line of enquiry to confirm understanding before
moving on to the next section.
• Signpost – when moving on to the next section use transitional statements to make it
clear to the examiner that you have a logical sequence in your process.
• Timing – ensure you keep to time (in both an exam setting and reality, time is your most
precious resource so make sure you use it as efficiently as possible).

BUILDING A RELATIONSHIP

NON-VERBAL BEHAVIOUR
• To patient – demonstrate an appropriate affect (e.g. eye contact, posture and position,
movement, facial expression, use of voice).
• Documentation – if writing notes or using a computer, do so in a way that doesn’t cause
a barrier towards dialogue and rapport.

RAPPORT
• Acknowledge – accept legitimacy of the patient’s views without being judgemental.
• Empathy – use empathy to communicate understanding of the patient’s feelings.
• Support – express concern and a willingness to help along with appropriate self-care
mechanisms.
• Sensitivity – deal sensitively with embarrassing topics; this is a closely scrutinised
area in final year OSCEs due to the challenging nature of communication in such
settings.

PATIENT INVOLVEMENT
• Share thinking – encourage patient involvement.
• Explain rationale – when asking sensitive questions, explain why this information is
important for you to understand.

EXPLANATION AND PLANNING (OFTEN COMES UNDER

“INFORMATION GIVING” IN AN OSCE FORMAT)

PROVIDE THE CORRECT AMOUNT AND TYPE OF INFORMATION

• Assess the patient’s starting point – establish the patient’s current understanding
of their problem (if any) at the outset; establish how much the patient wants to know;
remember even the brightest of patients only remembers so much.
• Chunks and checks – give information in digestible chunks; check for understanding;
use the patient’s response as a guide as to how much more is required.
xxiv
 Taking a focused history in OSCEs – The Calgary–Cambridge model

• Give explanations at the appropriate time – avoid giving advice, information or

reassurance prematurely (e.g. before important investigations are back to guide further
discussions).

AID ACCURATE RECALL AND UNDERSTANDING

• Organise explanation – have a logical approach (e.g. discussing patient’s symptoms →
condition → possible investigations → shared management → addressing further
concerns → follow-up).
• Use explicit categorisation or signposting – e.g. “There are three important things that
I would like to discuss with you” (try to make the most important issue the first one);
signpost to help the patient remember explanations.
• Use repetition and summarise – to reinforce and embed information in patients.
• Use visual aids – diagrams, models, written information and instructions.
• Use simple language – use concise, easily understood statements, avoid jargon; provide
examples.
• Check the patient’s understanding – e.g. by asking the patient to restate information in
their own words; clarify if necessary.

ACHIEVE A SHARED UNDERSTANDING: INCORPORATE THE

PATIENT’S ILLNESS FRAMEWORK
• Relate explanations to the patient’s perspective – relate information to previously
expressed ideas, concerns and expectations.
• Provide opportunities and encourage the patient to contribute – by asking questions,
seeking clarification or expressing doubts; respond appropriately.
• Identify and respond to verbal and non-verbal cues – listen to the patient’s responses to
information; only give as much information as the patient wishes to take in at that consultation.
• Elicit and assess the patient’s reactions and feelings – regarding information given,
terms used; acknowledge and clarify where necessary; check whether they wish you to
continue or discuss other concerns.

PLANNING: SHARED DECISION-MAKING

• Share own thoughts – ideas, thought processes and dilemmas.
• Involve the patient – offer suggestions rather than directives; “What would you like?”
• Encourage patient contribution – regarding their ideas, suggestions and preferences.
• Negotiate – negotiate a mutually acceptable plan.
• Offer choice – where desired, ask the patient to make informed choices and decisions.
• Check with the patient – if concerns have been addressed and whether they are happy
with the negotiated plan.

CLOSING THE SESSION

• End summary – summarise the session briefly and clarify the plan of care.
• Contract – agree with the patient on the next steps for both patient and physician.
xxv
 Taking a focused history in OSCEs – The Calgary–Cambridge model

• Safety net – explain possible unexpected outcomes, when and how to seek help.
• Final check – check whether patient agrees and is comfortable with the plan and ask for
any corrections, questions or other items to discuss.

The successful OSCE candidate is one who can successfully implement the Calgary–
Cambridge model whilst ensuring that key elements of the history are not left out.
It is important to remember that patients in reality can be unreliable, and so internal cross-
checking of event dates, past medical problems, etc., is a useful discipline. A simple example of
this is hypertension, which will not be admitted by many patients simply because they consider
that they no longer have it as they are now on anti-hypertensive medication. Use medica-
tions as a way of cross-checking the patient’s past medical history. Thus, levothyroxine in the
list of medications would indicate that the patient has hypothyroidism, even if not originally
volunteered.
There is an understandable danger of becoming too mechanical while information gather-
ing. Students need to do more than just “go through the motions” during the OSCE. A flat affect
with little empathy comes across clearly to examiners and will not help the cause. Although it
can be difficult to reconcile some scenarios with a clinical problem (e.g. a clearly normal simu-
lated patient giving a history of jaundice), every effort should be made to consider the scenario
in a real life concept.
A good general practitioner will tell you that most diagnoses are made from clinical history
alone and not from examinations or investigations. For the purposes of this book, examina-
tion has intentionally been left out as this is well covered in other textbooks. In some
OSCE ­s cenarios, history and examination go alongside one another. However, it remains
the case that a well-taken history will guide the candidate to a focussed and relevant
examination.
In some stations, the emphasis will also be on information giving. It is important here
to provide an appropriate level of reassurance and information if this is asked of you.
Finally, you should try to effect a proper closure to the interview, particularly in an OSCE.
Consider using phrases such as: “Is there anything we discussed that wasn’t entirely
clear?” or “Are there any further questions you would like me to answer?” to round off
your history. With such questions, it is preferable to put the emphasis on whether or not
you made it clear enough to the patient rather than whether they were able to understand
the information.
The structure of these scenarios can easily be used to develop an appropriate approach to
the OSLER (and other similar medical examinations), which is used in some medical schools
alongside the OSCE, either for formative or summative assessment.

A CONTENT GUIDE FOR HISTORY TAKING

The Calgary–Cambridge model incorporates the traditional medical approach (below left).
When recording the content of the medical interview, consider the adapted model on the right,
which is based on the Calgary–Cambridge model, as proposed by Silverman et al.

xxvi
 Taking a focused history in OSCEs – The Calgary–Cambridge model

Traditional medical approach Non-traditional approach

The history Adapted Calgary–Cambridge framework

Patient’s problem list
Presenting complaint 1.
2.
History of presenting complaint
Exploration of patient’s problems
Past medical history
Medical perspective (disease)
Sequence of events
Drug and allergy history
Symptom analysis
Relevant systems review
Family history
Patient’s perspective (illness)
Personal and social history Effects on life and feelings
Ideas
Concerns
Expectations

Background information – context

Past medical history
Drug and allergy history
Family history
Personal and social history
Review of systems

Physical examination Physical examination

Differential diagnosis Differential diagnosis/problem list

Investigations

Management Physician’s plan of management

Investigations
Treatment alternatives

xxvii
Another random document with
no related content on Scribd:
 Launcelot.—Nay, indeed, if you had your eyes, you might fail of
the knowing me: it is a wise father that knows his own child. Well, old
man, I will tell you news of your son: give me your blessing. Truth will
come to light; murder cannot be hid long,—a man’s son may; but, in
the end, truth will out.
Gobbo.—Pray you, sir, stand up: I am sure you are not Launcelot,
my boy.
Launcelot.—Pray you, let’s have no more fooling about it, but give
me your blessing: I am Launcelot, your boy that was, your son that
is, your child that shall be.
Gobbo.—I cannot think you are my son.
Launcelot.—I know not what I shall think of that: but I am
Launcelot, the Jew’s man; and I am sure Margery your wife is my
mother.
Gobbo.—Her name is Margery, indeed: I’ll be sworn, if thou be
Launcelot, thou art mine own flesh and blood. Lord, worship’d might
he be! What a beard hast thou got! thou hast got more hair on thy
chin than Dobbin, my fill-horse, has on his tail.
Launcelot.—It should seem, then, that Dobbin’s tail grows
backward: I am sure he had more hair of his tail than I have on my
face, when I last saw him.
Gobbo.—Lord, how art thou chang’d! How dost thou and thy
master agree? I have brought him a present. How ’gree you now?
Launcelot.—Well, well; but, for mine own part, as I have set up my
rest to run away, so I will not rest till I have run some ground. My
master’s a very Jew: give him a present! give him a halter: I am
famish’d in his service; you may tell every finger I have with my ribs.
Father, I am glad you are come: give me your present to one Master
Bassanio, who, indeed, gives rare new liveries: if I serve not him, I
will run as far as God has any ground.—O rare fortune! here comes
the man:—to him, father, for I am a Jew, if I serve the Jew any
longer.
—Act II, Scene II, Lines 29-104.
 HAMLET’S DECLARATION OF FRIENDSHIP

Hamlet. What ho! Horatio!

Horatio. Here, sweet lord, at your service.

Hamlet. Horatio, thou art e’en as just a man

As e’er my conversation coped withal.

Horatio. O, my dear lord,—

Hamlet. Nay, do not think I flatter;

For what advancement may I hope from thee
That no revenue hast, but thy good spirits,
To feed and clothe thee? Why should the poor be flatter’d?
No, let the candied tongue lick absurd pomp,
And crook the pregnant hinges of the knee
Where thrift may follow fawning. Dost thou hear?
Since my dear soul was mistress of her choice
And could of men distinguish, her election
Hath sealed thee for herself; for thou hast been
As one, in suffering all, that suffers nothing,
A man that fortune’s buffets and rewards
Hast ta’en with equal thanks: and blest are those
Whose blood and judgment are so well commingled
That they are not a pipe for Fortune’s finger
To sound what stop she pleases. Give me that man
That is not passion’s slave, and I will wear him
In my heart’s core, ay, in my heart of hearts,
As I do thee.

—From Act III, Scene 2.

OTHELLO’S APOLOGY
[The speech calls for great dignity, ease, and power, in both speech
and manner.]
Most potent, grave, and reverend signiors,
My very noble and approved good masters,
That I have ta’en away this old man’s daughter,
It is most true; true, I have married her:
The very head and front of my offending
Hath this extent, no more. Rude am I in my speech,
And little bless’d with the soft phrase of peace;
For since these arms of mine had seven years’ pith,
Till now some nine moons wasted, they have used
Their dearest action in the tented field,
And little of this great world can I speak,
More than pertains to feats of broil and battle,
And therefore little shall I grace my cause
In speaking for myself. Yet, by your gracious patience,
I will a round unvarnish’d tale deliver
Of my whole course of love; what drugs, what charms,
What conjuration, and what mighty magic,—
For such proceeding I am charg’d withal,—
I won his daughter.
...
Her father loved me; oft invited me;
Still question’d me the story of my life,
From year to year,—the battles, sieges, fortunes,
That I have pass’d.
I ran it through, even from my boyish days,
To the very moment that he bade me tell it:
Wherein I spake of most disastrous chances,
Of moving accidents by flood and field,
Of hair-breadth scapes i’ the imminent deadly breach,
Of being taken by the insolent foe
And sold to slavery, of my redemption thence
And portance in my travels’ history:
...

This to hear
Would Desdemona seriously incline:
But still the house-affairs would draw her thence;
Which ever as she could with haste despatch,
She’d come again, and with a greedy ear
Devour up my discourse: which I observing,
Took once a pliant hour, and found good means
To draw from her a prayer of earnest heart
That I would all my pilgrimage dilate,
Whereof by parcels she had something heard,
But not intentively: I did consent,
And often did beguile her of her tears,
When I did speak of some distressful stroke
That my youth suffer’d. My story being done,
She gave me for my pains a world of sighs:
She swore, in faith, ’twas strange, ’twas passing strange,
’Twas pitiful, ’twas wondrous pitiful:
She wish’d she had not heard it, yet she wish’d
That heaven had made her such a man: she thank’d me,
And bade me, if I had a friend that loved her,
I should but teach him how to tell my story,
And that would woo her. Upon this hint I spake:
She loved me for the dangers I had pass’d;
And I lov’d her that she did pity them.
This only is the witchcraft I have used.

THE SEVEN AGES

[This is a succession of purely imaginative ideas which the voice
should touch lightly. In this speech one meets always the question of
impersonation: shall the mewling infant, the whining schoolboy, the
sighing lover and the rest be imitated by the reader? It is in better
taste not to impersonate these seven characters beyond certain
almost imperceptible hints which the gayety of Jaques’s mind might
naturally throw off.]

All the world’s a stage,

And all the men and women merely players:
They have their exits and their entrances;
And one man in his time plays many parts,
His acts being seven ages. At first the infant,
Mewling and puking in the nurse’s arms:
And then the whining schoolboy, with his satchel
And shining morning face, creeping like snail
Unwillingly to school. And then the lover,
Sighing like furnace, with a woeful ballad
Made to his mistress’ eyebrow. Then a soldier,
Full of strange oaths and bearded like the pard,
Jealous in honor, sudden and quick in quarrel,
Seeking the bubble reputation
Even in the cannon’s mouth. And then the justice,
In fair round belly with good capon lined,
With eyes severe and beard of formal cut,
Full of wise saws and modern instances;
And so he plays his part. The sixth age shifts
Into the lean and slipper’d pantaloon,
With spectacles on nose and pouch on side;
His youthful hose, well saved, a world too wide
For his shrunk shank; and his big manly voice,
Turning again toward childish treble, pipes
And whistles in his sound. Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.

—“As You Like it,” Act II, Scene 7.

SOLITUDE PREFERRED TO COURT LIFE

Duke S. Now, my co-mates and brothers in exile,

Hath not old custom made this life more sweet
Than that of painted pomp? Are not these woods
More free from peril than the envious court?
Here feel we but the penalty of Adam.
The season’s difference, as the icy fang
And churlish chiding of the winter’s wind,
Which, when it bite and blows upon my body,
Even till I shrink with cold, I smile and say
’Tis no flattery; these are counselors
That feelingly persuade me what I am.
Sweet are the uses of adversity,
Which, like the toad, ugly and venomous,
Wears yet a precious jewel in his head;
And this our life, exempt from public haunt,
Finds tongues in trees, books in the running brooks,
Sermons in stones, and good in everything.
I would not change it.

Amiens. Happy is your grace,

That can translate the stubbornness of fortune
Into so quiet and so sweet a style.

...

Duke S. Come, shall we go and kill us venison?

And yet it irks me the poor dappled fools,
Being native burghers of this desert city,
Should in their own confines with forked heads
Have their round haunches gor’d.

—“As You Like It,” Act II.

THE POTION SCENE

Scene: Juliet’s Chamber

(Enter Juliet and Nurse, who bears wedding garments.)

Juliet (looking at garments).

Ay, those attires are best; but, gentle nurse,

I pray thee, leave me to myself to-night;
For I have need of many orisons
To move the heavens to smile upon my state,
Which, well thou knowest, is cross and full of sin.
 (Enter Lady Capulet.)

Lady Capulet.

What are you busy, ho? need you my help?

Juliet.

No, madam; we have cull’d such necessaries

As are behoveful for our state to-morrow:
So please you, let me now be left alone,
And let the nurse this night sit up with you;
For, I am sure, you have your hands full all,
In this so sudden business.

Lady Capulet (crossing and kissing Juliet on the forehead).

Good night;
Get thee to bed and rest, for thou hast need.

(Exit Lady Capulet with nurse.)

Juliet (looking after them).

Farewell! God knows when we shall meet again.

I have a faint cold fear thrills through my veins,
That almost freezes up the heat of life:
I’ll call them back again to comfort me. (Runs to R.)
Nurse! What should she do there?
My dismal scene I needs must act alone.
Come, vial. (Takes vial from bosom.)
What if this mixture do not work at all?
Shall I be married then to-morrow morning?
No, no! (draws dagger) this shall forbid it.

(Lays dagger on table.)

Lie you there. (To vial.)

What if it be a poison, which the friar
Subtly hath ministered to have me dead,
Lest in this marriage he should be dishonored
Because he married me before to Romeo?
I fear it is; and yet, methinks, it should not,
For he hath still been tried a holy man.

(Puts vial in bosom.)

How if, when I am laid into the tomb,

I wake before the time that Romeo
Come to redeem me? there’s a fearful point!
Shall I not then be stifled in the vault,
To whose foul mouth no healthsome air breathes in,
And there die strangled ere my Romeo comes?
Or, if I live, is it not very like,
The horrible conceit of death and night,
Together with the terror of the place,—
As in a vault, an ancient receptacle,
Where, for these many hundred years, the bones
Of all my buried ancestors are packed;
Where bloody Tybalt, yet but green in earth,
Lies festering in his shroud; where as they say,
At some hours in the night spirits resort; ...
O, if I wake, shall I not be distraught,
Environed with all these hideous fears?
And madly play with my forefathers’ joints?
And pluck the mangled Tybalt from his shroud?
And, in this rage, with some great kinsman’s bone,
As with a club, dash out my desperate brains?
O, look! methinks I see my cousin’s ghost
Seeking out Romeo, ...
Stay, Tybalt, stay!—
Romeo, I come! (Drawing out vial—then cork.)
This do I drink to thee.

(Throws away vial. She is overcome and sinks to the floor.)

—From “Romeo and Juliet,” Act IV, Scene 3.

 BANISHMENT SCENE
SCENE III, A ROOM IN THE PALACE
(Enter Celia and Rosalind.)
Cel. Why, cousin; why Rosalind;—Cupid have mercy;—Not a
word?
Ros. Not one to throw to a dog.
Cel. No, thy words are too precious to be cast away upon curs,
throw some of them at me; come, lame me with reasons.
Ros. Then there were two cousins laid up; when the one should be
lamed with reasons, and the other mad without any.
Cel. But is all this for your father?
Ros. No, some of it for my father’s child: O, how full of briars is this
working-day world!
Cel. They are but burrs, cousin, thrown upon thee in holiday
foolery; if we walk not in the trodden paths, our very coats will catch
them.
Ros. I could shake them off my coat; these burrs are in my heart.
Cel. Hem them away.
Ros. I would try; if I could cry hem, and have him.
Cel. Come, come, wrestle with thy affections.
Ros. O, they take the part of a better wrestler than myself.
Cel. Is it possible, on such a sudden, you should fall into so strong
a liking with old Sir Rowland’s youngest son?
Ros. The duke my father lov’d his father dearly.
Cel. Doth it therefore ensue, that you should love his son dearly?
By this kind of chase, I should hate him, for my father hated his
father dearly; yet I hate not Orlando.
Ros. No ’faith, hate him not, for my sake.
Cel. Why should I not? Doth he not deserve well?
 Ros. Let me love him for that; and do you love him, because I do:
Look, here comes the duke.
Cel. With his eyes full of anger.
(Enter Duke Frederick, with Lords.)
Duke F. Mistress, despatch you with your safest haste, and get
you from our Court.
Ros. Me, uncle?
Duke F. You, cousin, within these ten days if thou be’st found so
near our public court as twenty miles, thou diest for it.
Ros. I do beseech your grace, let me the knowledge of my fault
bear with me: if with myself I hold intelligence, or have acquaintance
with mine own desires; if that I do not dream, or be not frantic (as I
do trust I am not), then, dear uncle, never so much as in a thought
unborn, did I offend your highness.
Duke F. Thus do all traitors, if their purgation did consist in words,
they are as innocent as grace itself: let it suffice thee, that I trust thee
not.
Ros. Yet your mistrust cannot make me a traitor: tell me, whereon
the likelihood depends.
Duke F. Thou art thy father’s daughter, there’s enough.
Ros. So was I, when your highness took his dukedom; so was I,
when your highness banish’d him: treason is not inherited, my lord:
or, if we did derive it from our friends, what’s that to me? my father
was no traitor: then, good my liege, mistake me not so much, to think
my poverty is treacherous.
Cel. Dear sovereign, hear me speak.
Duke F. Aye, Celia; we stay’d here for your sake. Else had she
with her father rang’d along.
Cel. I did not then entreat to have her stay, it was your pleasure,
and your own remorse; I was too young that time to value her, but
now I know her; if she be a traitor, so am I: we still have slept
together; rose at an instant, learn’d, play’d, eat together;

And wheresoe’er we went, like Juno’s swans,

Still we went coupled, and inseparable.

Duke F. She is too subtle for thee; and her smoothness,

Her very silence, and her patience,
Speak to the people and they pity her.
Thou art a fool: she robs thee of thy name;
And thou wilt show more bright, and seem more virtuous,
When she is gone: then open not thy lips;
Firm and irrevocable is my doom
Which I have pass’d upon her; she is banish’d.

Cel. Pronounce that sentence then on me, my liege;

I cannot live out of her company.

Duke F. You are a fool:—You, niece, provide yourself;

If you outstay the time, upon my honor,
And in the greatness of my word, you die.

(Exeunt Duke Frederick and Lords.)

Cel. O my poor Rosalind: whither wilt thou go?

Wilt thou change fathers? I will give thee mine.
I charge thee, be not thou more griev’d than I am.

Ros. I have more cause.

Cel. Thou hast not, cousin,

Pr’ythee, be cheerful: know’st thou not, the duke
Hath banish’d me his daughter?

Ros. That he hath not.

Cel. No? hath not? Rosalind lacks then the love

Which teaches thee that thou and I art one:
Shall we be sunder’d? shall we part, sweet girl?
No; let my father seek another heir.
Therefore devise with me, how we may fly,
Whither to go, and what to bear with us:
And do not seek to take your charge upon you,
To bear your griefs yourself, and leave me out;
For by this heaven, now at our sorrows pale,
Say what thou can’st, I’ll go along with thee.

Ros. Why, whither shall we go?

Cel. To seek my uncle.

Ros. Alas, what danger will it be to us,

Maids as we are, to travel so far?
Beauty provoketh thieves sooner than gold.

Cel. I’ll put myself in poor and mean attire,

And with a kind of umber smirch my face;
The like do you; so shall we pass along,
And never stir assailants.

Ros. Were it not better,

Because that I am more than common tall,
That I did suit me in all points like a man?
A boar-spear in my hand; and in my heart
Lie there what hidden woman’s fear there will,
We’ll have a swashing and a martial outside;
As many other mannish cowards have,
That do outface it with their semblances.

Cel. What shall I call thee when thou art a man?

Ros. I’ll have no other worse than Jove’s own page,

And therefore, look you, call me Ganymede.
But what will you be call’d?

Cel. Something that hath a reference to my state:

No longer Celia, but Aliena.

Ros. But, cousin, what if we assayed to steal

The clownish fool out of your father’s court?
Would he not be a comfort to our travel?

Cel. He’ll go along o’er the wide world with me;

Leave me alone to woo him: Let’s away
And get our jewels and our wealth together;
Devise the fittest time, and safest way
To hide us from pursuit that will be made
After my flight: Now go we in content,
To liberty, and not to banishment.

—From “As You Like It,” Act I.

CORYDON
By Thomas Bailey Aldrich
SCENE, A ROAD-SIDE IN ARCADY

Shepherd. Good sir, have you seen pass this way

A mischief straight from market-day?
You’d know her at a glance, I think;
Her eyes are blue, her lips are pink;
She has a way of looking back
Over her shoulder, and alack!
Who gets that look one time, good sir,
Has naught to do but follow.

Pilgrim. I have not seen this maid methinks,

Though she that passed had lips like pinks.

Shepherd. Or like two strawberries made one

By some sly trick of dew and sun.

Pilgrim. A poet.
Shepherd. Nay, a simple swain
That tends his flocks on yonder plain
Naught else I swear by book and bell.
But she that passed you marked her well
Was she not smooth as any be
That dwells here—in Arcady?

Pilgrim. Her skin was the satin bark of birches.

Shepherd. Light or dark?

Pilgrim. Quite dark.

Shepherd. Then ’twas not she.

Pilgrim. The peaches side

That next the sun is not so dyed
As was her cheek. Her hair hung down
Like summer twilight falling brown;
And when the breeze swept by, I wist
Her face was in a somber twist.

Shepherd. No that is not the maid I seek;

Her hair lies gold against her cheek,
Her yellow tresses take the morn,
Like silken tassels of the corn,
And yet brown-locks are far from bad.

Pilgrim. Now I bethink me this one had

A figure like the willow tree
Which, slight and supple, wondrously
Inclines to droop with pensive grace,
And still retain its proper place.
A foot so arched and very small
The marvel was she walked at all;
Her hand in sooth, I lack for words—
Her hand, five slender snow-white birds,
Her voice, tho’ she but said “God Speed”—
Was melody blown through a reed;
The girl Pan changed into a pipe
Had not a note so full and rife.
And then her eye—my lad, her eye!
Discreet, inviting, candid, shy,
An outward ice, an inward fire,
And lashes to the heart’s desire.
Soft fringes blacker than the sloe—

Shepherd. Good sir, which way did this one go?

Pilgrim. So he is off! The silly youth

Knoweth not love in sober sooth,
He loves—thus lads at first are blind—
No woman, only womankind.
I needs must laugh, for by the mass
No maid at all did this way pass.
 PART FOUR
Oratoric Reading and the Art of Public Speech
Discussion of forceful speech in making history. Value of forceful
speech. Practice selections.

HAMLET’S INSTRUCTION TO THE PLAYERS

Speak the speech, I pray you, as I pronounced it to you,—
trippingly on the tongue; but if you mouth it, as many of our players
do, I had as lief the town-crier spake my lines. Nor do not saw the air
too much with your hand, thus, but use all gently; for in the very
torrent, tempest, and, as I may say, whirlwind of your passion, you
must acquire and beget a temperance, that may give it smoothness.
Oh! it offends me to the soul to hear a robustious periwig-pated
fellow tear a passion to tatters,—to very rags,—to split the ears of
the groundlings; who, for the most part, are capable of nothing but
inexplicable dumb show and noise. I would have such a fellow
whipped for o’erdoing Termagant; it out-herods Herod. Pray you
avoid it.
—Shakespeare.
 CHAPTER XIII
ORATORIC READING AND THE ART OF PUBLIC SPEECH

Upon this important subject of public speaking, and the

interpretation of the addresses made by others, great men have thus
expressed themselves: Dr. Charles W. Eliot, formerly President of
Harvard University, says: “Have we not all seen, in recent years, that
leading men of business have a great need of a highly trained power
of clear and convincing expression? Business men seem to me to
need, in speech and writing, all the Roman terseness and the French
clearness. That one attainment is sufficient reward for the whole long
course of twelve years spent in liberal study.” Abraham Lincoln
likewise said: “Extemporaneous speaking should be practiced and
cultivated. It is the lawyer’s avenue to the public. However able and
faithful he may be in other respects, people are slow to bring him
business if he can not make a speech.”
Every thinker knows what a vital part eloquence plays in national
as well as individual welfare. If at first thought effective speaking
seems a simple thing and a superficial part of education, on mature
thought and consideration it will be found to be one of the most
complex, vital and difficult problems that education has to meet. And
yet, notwithstanding this complexity of the problem, the teacher is
cheered by the delightful assurance of giving the student a
consciousness of his latent talents and the ability to reveal and make
use of them for the proper influencing of his fellow men.
There is a belief fairly commonly held that only a limited few need
study the art of public speaking. Never was there a greater error or a
more fatal mistake—especially in a republic like ours, where every
man should be vitally interested in public affairs. No single citizen
can afford not to be able to stand before his fellows and clearly,
pleasingly and convincingly present his ideas upon any subject of
local, state, or national importance. It is no more an ornamental
accomplishment than is grammar, penmanship or simple arithmetic.
It should be as universal as “the three r’s.” The hints and selections
that follow are carefully chosen to incite every good citizen to the
acquirement of this useful and practical aid for his own benefit as
well as that of his fellows. All the lessons and analyses that have
gone before in these pages will materially aid in the elucidation of
these brief lessons.
The basis for development in Effective Speaking rests upon one’s
bodily, emotional and mental agencies of expression, and a
knowledge of their respective importance and efficient use. That
which counts most for development is conscientious practice; without
which, progress is impossible.
There are three definite means of communicating thought and
feeling to others: (a) Pantomime: face, hands, body; (b) Vocal: tone
sound; (c) Verbal: words, which are conventional symbols
manifesting mental and emotional states.
The problem, then, is to obtain a harmonious coördination of these
three languages. In other words, the content of the word when
spoken should be reflected in the tone and in the body. Thus speech
becomes effective merely because it receives its just and fair
consideration.
With this general understanding let us take up and master the
successive steps which ultimately lead to a realization of the desired
end.
The first important essential of effective speaking is the Spirit of
Directness. By this is meant natural, unaffected speech. Nothing can
be more important than that the person speaking use in public
address the ordinary elements of Conversation.
Hence, the first step is practice in natural speaking. Commit to
memory Hamlet’s Instructions to the Players given on a preceding
page. Do this not line by line, but the entire selection as a whole.
First: Read it through silently three times to familiarize yourself with
the subject-matter. Second: Read it aloud at least five times. Third:
Speak it conversationally at least five times from memory. In this
practice always be intensely conscious that you are addressing an
individual and not an audience.
 Now take any of the prose or poetic selections from the earlier
pages of this book, memorize them, after studying them as the
instructions require, and speak them directly and naturally, in the
ordinary conversational style.
Sufficient practice in this is the necessary preparation for the next
step, viz., the acquiring of a natural elevated conversational style,
which is merely another name for the higher type of public speaking.
Commit all, or a part, of the following selections, keeping in mind
that in speaking them you are addressing a group of people.

THE GETTYSBURG ADDRESS

By Abraham Lincoln
Fourscore and seven years ago our fathers brought forth upon this
continent a new nation, conceived in liberty, and dedicated to the
proposition that all men are created equal. Now we are engaged in a
great Civil War, testing whether that nation, or any nation, so
conceived and so dedicated, can long endure. We are met on a
great battlefield of that war. We are met to dedicate a portion of it as
the final resting place of those who here gave their lives that that
nation might live.
It is altogether fitting and proper that we should do this. But in a
larger sense we cannot dedicate, we cannot consecrate, we cannot
hallow this ground. The brave men, living and dead, who struggled
here, have consecrated it far above our power to add or detract. The
world will little note, nor long remember, what we say here, but it can
never forget what they did here.
It is for us, the living, rather to be dedicated here to the unfinished
work they have thus far so nobly carried on. It is rather for us to be
here dedicated to the great task remaining before us, that from these
honored dead we take increased devotion to the cause for which
they gave their last full measure of devotion; that we here highly
resolve that these dead shall not have died in vain, that the Union
shall, under God, have a new birth of freedom, and that the
government of the people, by the people, and for the people, shall
not perish from the earth.

By this time you should have mastered Ordinary Conversational

Style; Elevated Conversational Style; and Abandon and Flexibility of
Speech. The next consideration is the importance of Clearness.
Clearness in speech means making prominent central words and
subordinating unimportant words, or phrases. In other words, the
logical sequence of thought must be clearly shown. This is brought
about by a variety of inflections, changes of pitch, pause, etc.
Clearness in speech is dependent upon clearness of Thinking.
It is important now to give full consideration to the subject of
Emphasis. There are more ways than one of emphasizing your
thought. The most common way is by merely increasing the stress of
voice upon a word. This, however, is the most undignified form of
emphasis. It is common to ranters and “soap-box” orators and is one
mark of an undisciplined and uncultured man. Remember that
loudness is a purely physical element, and does not manifest
thought. Such emphasis is an appeal to the brute instinct, and is only
expressive of the lower emotions. But Inflection, Changes of Pitch,
Pause, Movement and Tone-Color—as have been fully explained in
preceding pages—all appeal to the exalted nature of man.
In proportion to the nobleness of an emotion or thought, we find a
tendency to accentuate these above-named elements. Such
methods of emphasis are appropriate to the most disciplined and
cultured man. More than that, they are the surest evidence of a great
personality.
Commit, then make clear to the hearer, the vital thought in the
following:

He have arbitrary power! My lords, the East India Company

have not arbitrary power to give him; the King has no arbitrary
power to give him; your Lordships have not; nor the
Commons; nor the whole legislature. We have no arbitrary
power to give, because arbitrary power is a thing which